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MisdiagnosisMisdiagnosisNot your basic Not your basic acute sinusitisacute sinusitis
Mary ThomasonMary Thomason
March 8, 2006March 8, 2006
No Financial DisclosuresNo Financial Disclosures
Case PresentationCase Presentation 55 yo female with PMH significant for 55 yo female with PMH significant for
presumed acute sinusitis in March/April of presumed acute sinusitis in March/April of 2005 requiring 6 weeks of antibiotics who 2005 requiring 6 weeks of antibiotics who presented with HA and nasal congestion.presented with HA and nasal congestion.
12/2/05 at urgent care 12/2/05 at urgent care dx: Acute Sinusitis tx: 2 Z-Paksdx: Acute Sinusitis tx: 2 Z-Paks
12/6/05 in clinic12/6/05 in cliniccc: headache dx:? tx: complete cc: headache dx:? tx: complete
antibiotics antibiotics and follow up in one and follow up in one weekweek
Case PresentationCase Presentation
12/16/05 clinic followup12/16/05 clinic followup
cc: headache and nasal congestioncc: headache and nasal congestion
dx: persistent URI symptomsdx: persistent URI symptoms
tx: nasal steroids and sinus CT tx: nasal steroids and sinus CT scanscan
12/19/05 radiology12/19/05 radiology
CT scan negative for acute CT scan negative for acute sinusitis or sinusitis or congestioncongestion
Case PresentationCase Presentation
12/30/05 clinic follow up12/30/05 clinic follow up Dx: Carbon Monoxide (CO) Dx: Carbon Monoxide (CO)
PoisoningPoisoning
ObjectivesObjectives
Recognize symptoms of CO exposureRecognize symptoms of CO exposure Diagnosis of CO exposureDiagnosis of CO exposure Treatment of CO exposureTreatment of CO exposure Prevention of CO exposurePrevention of CO exposure
PhysiologyPhysiology
CO diffuses CO diffuses rapidly over the rapidly over the alveolar alveolar membranemembrane
Binds reversibly Binds reversibly with 200-fold with 200-fold affinity to Hgbaffinity to Hgb
Shifts the Shifts the oxyhemoglobin oxyhemoglobin dissociation curvedissociation curve
StatisticsStatistics
Leading cause of accidental Leading cause of accidental poisoning death in the USpoisoning death in the US
Estimated 15,000 treated annually in Estimated 15,000 treated annually in EDED
Approximate 500 deaths annuallyApproximate 500 deaths annually
JAMA vol. 293, no. 10, 3/9/05, 1183-86JAMA vol. 293, no. 10, 3/9/05, 1183-86
CO SourcesCO Sources
FurnacesFurnaces GeneratorsGenerators Gas heatersGas heaters Motor vehicles (cars, trucks, Motor vehicles (cars, trucks,
tractors, boats)tractors, boats) FiresFires
ExposuresExposures
Majority of CO Majority of CO exposures occur exposures occur in the fall and in the fall and winter monthswinter months
64.3% occur in 64.3% occur in the homethe home
18.5% due to 18.5% due to faulty furnacesfaulty furnaces
9% motor vehicles9% motor vehiclesJAMA vol. 293, no. 10, 3/9/05, JAMA vol. 293, no. 10, 3/9/05, 1183-861183-86
CO Exposure After CO Exposure After KatrinaKatrina
51 cases reported 51 cases reported by HBO2 facilities by HBO2 facilities of AL, LA, MSof AL, LA, MS
46 nonfatal, 5 46 nonfatal, 5 deathsdeaths
The source for all The source for all but one of the but one of the non-fatal cases non-fatal cases was exhaust from was exhaust from a portable a portable generator. generator. MMWR vol. 54, no. 39, 10/7/05, MMWR vol. 54, no. 39, 10/7/05,
996-998996-998
Symptoms of Mild Symptoms of Mild PoisoningPoisoning
Throbbing temporal or frontal HAThrobbing temporal or frontal HA FatigueFatigue WeaknessWeakness LightheadednessLightheadedness Nausea/VomitingNausea/Vomiting Shortness of BreathShortness of Breath
Symptoms of Moderate Symptoms of Moderate PoisoningPoisoning
Severe HASevere HA Tachycardia/TachypneaTachycardia/Tachypnea Flushing, perspirationFlushing, perspiration Diminished manual Diminished manual
dexterity/prolonged reaction timedexterity/prolonged reaction time Impaired judgment/confusionImpaired judgment/confusion Vision changes (darkened, blurred)Vision changes (darkened, blurred) TinnitusTinnitus
Symptoms of Severe Symptoms of Severe PoisoningPoisoning
SyncopeSyncope SeizuresSeizures MIMI DysrhythmiasDysrhythmias Respiratory failure/ pulmonary Respiratory failure/ pulmonary
edemaedema ComaComa DeathDeath
Delayed EffectsDelayed Effects
DepressionDepression Dementia/Memory LossDementia/Memory Loss PsychosisPsychosis Peripheral neuropathyPeripheral neuropathy ParkinsonismParkinsonism Visual impairmentVisual impairment ChoreaChorea
Diagnosis of CO Diagnosis of CO poisoningpoisoning
Have a high clinical suspicionHave a high clinical suspicion Determine the COHb level when the Determine the COHb level when the
pt is first seen and repeat q2-4 hours pt is first seen and repeat q2-4 hours until pt is asymptomatic or the value until pt is asymptomatic or the value is normal.is normal.
If symptomatic or COHb greater than If symptomatic or COHb greater than 20% monitor with ECG, lytes, CK, UA, 20% monitor with ECG, lytes, CK, UA, ABG to evaluate for sequellaABG to evaluate for sequella
Poisindex (accessed feb 2006)Poisindex (accessed feb 2006)
Range of ToxicityRange of Toxicity
Normal COHb is 1-3%Normal COHb is 1-3% Cigarette smokers increase their levels by 5% Cigarette smokers increase their levels by 5%
per pack per day (may tolerate up to 10%)per pack per day (may tolerate up to 10%) Toxic affects appear at 15-20%Toxic affects appear at 15-20% COHb levels above 25% are considered severe COHb levels above 25% are considered severe Toxicity however is determined Toxicity however is determined
symptomatically (cardiovascular and mental symptomatically (cardiovascular and mental status)status)
NEJM vol. 347, no. 14, 10/3/02, 1054-55NEJM vol. 347, no. 14, 10/3/02, 1054-55
When to HospitalizeWhen to Hospitalize
Neurologic signsNeurologic signs Abnormal ECGAbnormal ECG Metabolic AcidosisMetabolic Acidosis
TreatmentTreatment
Decontamination –Decontamination –move to fresh airmove to fresh air
Administer 100% Administer 100% oxygen (x 6 hours)oxygen (x 6 hours)
Consider hyperbaric Consider hyperbaric oxygen for severely oxygen for severely poisoned (coma, poisoned (coma, seizures, MI) and seizures, MI) and pregnant patients at pregnant patients at 3 atmospheres 3 atmospheres absolute.absolute. NEJM vol. 347, no. 14, 10/3/02, 1057-67NEJM vol. 347, no. 14, 10/3/02, 1057-67
Guideline to prevent CO Guideline to prevent CO exposureexposure
Service heating system/water heater yearlyService heating system/water heater yearly Install a battery-operated CO detector and Install a battery-operated CO detector and
check the batteries twice yearlycheck the batteries twice yearly Do not use charcoal grill or camp stove Do not use charcoal grill or camp stove
inside the home, garage, or near a windowinside the home, garage, or near a window Do not run vehicle inside garageDo not run vehicle inside garage Do no use stove or fire place that isn’t Do no use stove or fire place that isn’t
ventedvented Do not heat your home with a gas ovenDo not heat your home with a gas ovenJAMA vol. 293, no. 10, 3/9/05, 1183-86JAMA vol. 293, no. 10, 3/9/05, 1183-86
SummarySummary
Leading cause of accidental poisoning death Leading cause of accidental poisoning death in the USin the US
Mild symptoms are similar to a viral illness, Mild symptoms are similar to a viral illness, therefore a high index of suspicion is therefore a high index of suspicion is requiredrequired
CO poisoning is diagnosed symptomatically, CO poisoning is diagnosed symptomatically, but CO level testing can be helpfulbut CO level testing can be helpful
The mainstay of treatment is oxygen therapyThe mainstay of treatment is oxygen therapy Prevention is the keyPrevention is the key
Questions?Questions?
ReferencesReferences PoisindexPoisindex NEJM vol. 347, no. 14, 10/3/02, 1054-55NEJM vol. 347, no. 14, 10/3/02, 1054-55 NEJM vol. 347, no. 14, 10/3/02, 1057-67NEJM vol. 347, no. 14, 10/3/02, 1057-67 MMWR vol. 54, no. 39, 10/7/05, 996-998MMWR vol. 54, no. 39, 10/7/05, 996-998 JAMA vol. 293, no. 10, 3/9/05, 1183-86JAMA vol. 293, no. 10, 3/9/05, 1183-86 JAMA vol. 295, no. 4, 1/25/06, 398-402 JAMA vol. 295, no. 4, 1/25/06, 398-402 American Journal of Emergency Medicine, American Journal of Emergency Medicine,
Vol. 23, 3/23/05, 838-841Vol. 23, 3/23/05, 838-841
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